Time for Timeliness: A Proposal for Establishing Time to Treatment Initiation as a Quality Measure
Authors: Vikas Mehta, Risha Sheni
Journal: Journal of the National Comprehensive Cancer Network (2022)

A diagnosis of cancer, which approximately 40% of those born in the United States will receive in their lifetime, is a major life-defining moment that often results in significant physical, mental, emotional, and financial strain for patients and their families. 1Understandably, patients expect, and deserve, timely treatment of their cancer.Delays in treatment can have devastating consequences, including a significant impact on cancer burden, recurrence, and mortality.A portion of the delay in time to treatment initiation (TTI) can certainly be attributed to the increasing complexities of modern cancer care, which often involve various pretreatment imaging modalities, genomics, ancillary services, and multidisciplinary/multimodality therapeutic planning; all of which require ever-increasing administrative burden due to the authorization process for each step in our fee-for-service healthcare system.Navigating this complex pretreatment process while simultaneously dealing with a new cancer diagnosis presents a significant challenge for any individual, and there are not always adequate resources to help patients.Additionally, these treatment delays disproportionately occur within marginalized communities due to underlying challenges with social determinants of health, baseline disengagement with the healthcare system, and issues with healthcare literacy that can limit the ability of a patient and their family to advocate for timely and appropriate care.Delayed TTI thus serves as a major source of disparities seen in oncologic outcomes.We propose instituting TTI as an oncology, site-specific quality measure as a means to improve oncologic outcomes, especially for disparate populations.Delays in TTI of cancer care are associated with worse survival outcomes for several different cancer sites and types.Khorana et al 2 found in a large cohort study using National Cancer Database records of .3.5 million US patients newly diagnosed with cancer that TTI lengthened by 38% (range, 20%-86%) for stage I-III breast, prostate, lung, colorectal, renal, and pancreas cancer from 2004 through 2013.The overall median TTI was 21 days in 2004 to 2005 and increased to a median of 29 days in 2013 to 2014.For early-stage breast, lung, renal, and pancreas cancers, TTI was also found to be associated with absolute increased risk of mortality from 1.2% to 3.2% per week of delay.The most substantial differences were seen with 6 weeks used as a TTI cutoff point, with a 5-year overall survival rate of 56% versus 43% for #6 versus .6 weeks, respectively, in patients with stage I nonsmall cell lung cancer, and 38% versus 29%, respectively, in those with stage I pancreas cancer (P,.001 for both).Hanna et al 3 published a large systematic review and meta-analysis including 34 studies, 7 major cancer types, 3 treatment modalities (surgery, systemic treatment, and radiation therapy), and nearly 1.3 million patients in total.The meta-analysis found that across all 3 treatment modalities, a delay of 4 weeks was associated with increased risk of death.For example, surgical delay ranged from a 6% increased risk of death for each 4-week delay in TTI in breast cancer to 8% for head and neck cancer.The greatest deleterious effect was seen in adjuvant systemic treatment for colorectal cancer, for which there was a 13% increased risk of death for each 4-week delay in TTI.Additionally, the negative impact of delay on survival worsens with longer delays.For breast cancer surgery, a delay of 8 weeks and 12 weeks increased the risk of death by 17% and 26%,